Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 26, 2020; 8(22): 5535-5546
Published online Nov 26, 2020. doi: 10.12998/wjcc.v8.i22.5535
High serum lactate dehydrogenase and dyspnea: Positive predictors of adverse outcome in critical COVID-19 patients in Yichang
Xiao-Ting Lv, Yong-Ping Zhu, Ai-Guo Cheng, Yong-Xu Jin, Hai-Bo Ding, Cai-Yun Wang, Shu-Yu Zhang, Gong-Ping Chen, Qing-Quan Chen, Qi-Cai Liu
Xiao-Ting Lv, Yong-Xu Jin, Hai-Bo Ding, Cai-Yun Wang, Gong-Ping Chen, Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, Fujian Province, China
Xiao-Ting Lv, Institute of Respiratory Disease, Fujian Medical University, Fuzhou 350005, Fujian Province, China
Yong-Ping Zhu, Department of Cardiovascular Surgery, Fujian Medical University Attached Union Hospital, Fuzhou 350001, Fujian Province, China
Ai-Guo Cheng, Department of Critical Medicine, the Third People's Hospital of Yichang, Yichang 443000, Hubei Province, China
Shu-Yu Zhang, Qing-Quan Chen, Department of Laboratory Medicine, Fujian Medical University, Fuzhou 350004, Fujian Province, China
Qi-Cai Liu, Department of Reproductive Medicine Centre, First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, Fujian Province, China
Author contributions: Lv XT, Zhu YP, Chen GP and Liu QC contributed equally to this work; Chen GP, Chen QQ, and Liu QC designed the research study; Cheng AG, Jin YX, Ding HB, Wang CY and Zhang SY performed the research; Cheng AG, Jin YX, Ding HB and Lv XT contributed reagents and analytic tools; Lv XT and Zhu YP analyzed the data and wrote the manuscript; all authors have read and approve the final manuscript.
Supported by National Natural Science Foundation of China, No. 81800070; Development Fund Program of Fujian Provincial Health and Family Planning Commission, China, No. 2017-1-43.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Fujian Medical University [(No. (2020) 153)].
Informed consent statement: Patients were not required to give informed consent to the study as the analysis used anonymous clinical data that were obtained after each patient gave their informed verbal consent prior to study inclusion.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Qi-Cai Liu, MD, Chief Technician, Doctor, Teacher, Department of Reproductive Medicine Centre, First Affiliated Hospital of Fujian Medical University, No. 20 Chazhong Road, Taijiang District, Fuzhou 350005, Fujian Province, China. lqc673673673@163.com
Received: April 26, 2020
Peer-review started: April 26, 2020
First decision: August 23, 2020
Revised: September 4, 2020
Accepted: September 16, 2020
Article in press: September 16, 2020
Published online: November 26, 2020
Processing time: 212 Days and 21.5 Hours
Abstract
BACKGROUND

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in China, constitutes a Public Health Emergency of International Concern. It is well known that COVID-19 patients may have increased serum lactate dehydrogenase (LDH) levels in the early stage. The clinical changes in LDH may have predictive value in disease evolution and prognosis in critically ill COVID-19 patients.

AIM

To examine serum LDH and clinical characteristics in patients with COVID-19 and their predictive value for prognosis.

METHODS

This retrospective study analyzed the clinical data of forty-seven critical COVID-19 patients in the intensive care unit of the Third People's Hospital of Yichang City from January 27 to March 25, 2020 and divided them into survivors and non-survivors. The patients were diagnosed according to the World Health Organization interim guidance and critical cases met any one of the following criteria: Respiratory failure and required mechanical ventilation, the occurrence of shock, and the combined failure of other organs that required intensive care unit monitoring and treatments, according to the diagnostic criteria of critical COVID-19. Clinical data including symptoms, detection of SARS-CoV-2, chest computed tomography (CT) images, changes in serum LDH in different clinical phases, and prognosis were collected. Statistical analysis of the data was performed. Continuous variables were expressed as median (interquartile range) and compared with the Mann-Whitney U test. Categorical variables were compared with the Chi-square test. Survival data were analyzed using Kaplan-Meier survival curves and log-rank tests.

RESULTS

According to chest CT images, we observed the alveolitis and fibrosis stages in all critical patients in this study. Most non-survivors died in the fibrosis stage. Non-survivors had fewer days of hospitalization, shorter disease duration, shorter duration of alveolitis and fibrosis, and had dyspnea symptoms at disease onset (P = 0.05). Both first and lowest LDH values in the alveolitis stage were more pronounced in non-survivors than in survivors (449.0 U/L vs 288.0 U/L, P = 0.0243; 445.0 U/L vs 288.0 U/L, P = 0.0199, respectively), while the first, lowest and highest values of serum LDH in non-survivors were all significantly increased compared to survivors in the fibrosis phase (449.0 U/L vs 225.5 U/L, P = 0.0028; 432.0 U/L vs 191.0 U/L, P = 0.0007; 1303.0 U/L vs 263.5 U/L, P = 0.0001, respectively). The cut-off points of first LDH values in the alveolitis and fibrosis phase for distinction of non-survivors from survivors were 397.0 U/L and 263.0 U/L, respectively. In the fibrosis stage, non-survivors had more days with high LDH than survivors (7.0 d vs 0.0 d, P = 0.0002). Importantly, patients with high LDH had a significantly shorter median survival time than patients with low LDH in the alveolitis phase (22.0 d vs 36.5 d, P = 0.0002), while patients with high LDH also had a significantly shorter median survival time than patients with low LDH in the fibrosis phase (27.5 d vs 40.0 d, P = 0.0008). The proportion of non-survivors with detectable SARS-CoV-2 until death in the alveolitis stage was significantly increased compared with that in the fibrosis stage (100% vs 35.7%, P = 0.0220).

CONCLUSION

High LDH and dyspnea symptoms were positive predictors of an adverse outcome in critical COVID-19. The rapid progressive fibrosis stage was more perilous than the alveolitis stage, even if SARS-CoV-2 is undetectable.

Keywords: COVID-19; SARS-CoV-2; Lactate dehydrogenase; Pulmonary fibrosis; Dyspnea; Overall survival

Core Tip: We examined the serum lactate dehydrogenase (LDH) and clinical characteristics in critical coronavirus disease 2019 (COVID-19) patients and their predictive value for prognosis. We retrospectively evaluated 47 critical COVID-19 patients and divided them into non-survivors and survivors. Clinical data including symptoms, detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), chest computed tomography images, changes in serum LDH in different clinical phases, and prognosis were collected. In this study, high LDH was positively correlated with worsening overall survival. High LDH and dyspnea symptoms were positive predictors of adverse outcome in critical COVID-19 patients. The rapid progressive fibrosis stage may be more perilous than the alveolitis stage, even if SARS-CoV-2 is undetectable.